We’ve invested $ billions upon $ billions in interoperability. It’s past time to ask, “Is it a lost cause?”
Incentives insufficient to fix market dynamics?
Don’t worry folks, Congress is on the job. The problem has gotten so bad or become so old that we finally had congressional hearings last week on health record interoperability. There was predictable scolding and sound bites, and much of the testimony would have been the same 5 years ago, 10 years ago, or more ago, because the problem is exactly the same.
“In more competitive markets, hospitals don’t want to share data,” said Julia Adler-Milstein, assistant professor of information at the University of Michigan’s School of Public Health. There’s “no business case for interoperability,” via Healthcare IT News.
The song remains the same. The problems, most people know, are not technological (we can integrate when we want to), but business problems. The idea is, of course, that incentives could fix this, either meaningful use or pay-for-value.
It’s a good and valiant idea I have supported, but we need to face it: expecting competing providers to interoperate is like asking hyenas and lions to cooperate. Why would a hosptial CFO spend money on interoperability so that the organization will decrease the overall number of billing codes or send them across town? (Yes, there are many ethical reasons, but even the best-intentioned hospital execs have a tough time fighting against dollars over time, or investing in lost revenue).
No matter how many incentives you create, if some billing codes go to your account, and another set of billing codes go to a competitor’s account, they’re not going to invest in decreased billing. The pay-for-value measures are a great start, but it’s still unclear that coordination billing codes or value-based payments are enough to make a case for spending on the costs of coordination or lost fee-for-service billing.
“Robert Wergin, MD, president of the American Academy of Family Physicians, said that although family physicians have been on board with health IT since the beginning, they’re having a difficult time with the Stage 2 Meaningful Use requirements. In fact, some 55 percent of physicians indicated they would be skipping Stage 2 all together. The “time, expense and effort it takes makes it not worth while,” said Wergin.” ..also via Healthcare IT News.
That was at the beginning of last week, then at the end of last week, Stage 3 meaningful rules were released.
In the release, Patrick Conway, CMS acting principal deputy administrator and chief medical officer, said, “This Stage 3 proposed rule does three things: it helps simplify the meaningful use program, advances the use of health IT toward our vision for improving health delivery and further aligns the program with other quality and value programs.”
Lofty, good goals, but will it be enough to drive interoperability? As Vince Kuraitis astutely put it, MU was front-loaded with incentives, back-loaded with actual work, so there’s not a lot of leverage left.
— Vince Kuraitis (@VinceKuraitis) March 23, 2015
Old systems were architected to fix old problems, billing. For new payments, we need new systems and a new architecture built around individuals. We’re nearing the breaking point.
Theft and Fraud
Meanwhile, Premera just had over 10 million records breeched this month, most of those included things like social security numbers, birthdays and other highly personal information that could be used for identity theft, plus clinical information. Add that to tens of millions of accounts hacked over the previous year. It’s not slowing down. Just like interoperability, there’s no business case for the amount of security needed to protect records that are worth 10X more than credit card numbers on the black market (and some records even have credit card numbers, an added hacker bonus!).
Articles have stated that security must be “instilled in the organization,” but it’s hard for any organization to invest the kind of money (much less achieve the culture change) needed to keep the wolves outside the door when there are 10 million records, with a black market value of $100’s of million of dollars on the other side of that door. If a health record is worth $50 on the black market, can we expect every stakeholder to invest that much in security? Would a half billion dollar investment have been enough to protect them?
I’m guessing not. It’s a systemic problem that requires a systemic fix, and having the data all over everywhere is part of the problem. We simply can’t protect it all when the data is everywhere. There’s just too many weak links, too many vulnerability holes to plug.
Personal data will eclipse institution health data
Point of care data is a limited set. In a great talk on the future of “real world” personal health data, Maneesh Juneja quotes VA Director for Connected Health, Kathleen Frisbee who says “We predict patient-generated data will be much larger in volume than electronic health records.” To understand health, we need to coordinate data from when people are not sick. PHI will eclipse clinical health information in the years ahead.
So where should the data reside? In an EHR?
Clinical research turning patient-centered
Apple’s ResearchKit was announced a couple of weeks ago, representing a whole new method for clinical trials. See Eric Topol’s excellent post on the subject. He says “the new mobile medical research platform may turn out to be the most important advance in the history of clinical research.” Strong words. But all these example raise the question, where will all this data live?
We must ask ourselves: How could we do such a thing on a truly global scale? Where will such a record reside? Several are already working on one record of data. Robert Rowley and his team at Flow Health are working on a unified record. He recently asked “ Is Universal Health Data Platforms the ‘Holy Grail’ of Interoperability?” I think he’s part right, but I think interoperability is the wrong idea, we need one record to rule them all, and all services need to connect with that one record.
One of the basic rules of information management, and not a new rule at that, is that you should never manage the same data in two places, you should point to the “single source of truth” wherever possible. The individuals (all of us) most invested in their personal information must be enabled with the tools to protect that personal information, not trust that protection to a third party. Personal health information is becoming simultaneously too valuable and too expensive to do it any other way.
This may be the darkest hour, but I’m really hoping this will very soon look like the dark ages of health IT because this just isn’t working in a multitude of ways.
Ubiquitous connectivity, strong identity, and cryptography are combining to create new ways of making this work
With ubiquitous connectivity, strong identity mechanisms and cryptography, we have the basic building blocks to make this work. I’ll be talking a lot more in the weeks and months ahead. One of the big themes at SXSW on health was personal health data access and ownership. I this is on the right track.
The winning theme of digital health @ SXSW was “personal data access and ownership”
— Christine Lemke (@cklemke) March 17, 2015
We’ve started unpatient.org to work on some of these problems. I suspect (and deeply hope) we’ll think of interoperability much differently in a few years.